RN exams clinical judgment practice questions, set 164
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 164
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Five clinical judgment questions with answers
Cover the key. Write the first action. Then open the rationale and name why the other choices fail.
Question 1
A nurse is planning care for a client who is postpartum and has cardiac disease. Which of the following actions should the nurse include in the plan?
A. Monitor the client\'s weight weekly.
B. Monitor blood pressure daily.
C. Monitor fluid intake and output.
D. Monitor for signs of heart failure.
Show answer and rationale
Correct answer: D — Monitor for signs of heart failure.
The correct answer is D: Monitor for signs of heart failure. Postpartum clients with cardiac disease are at increased risk of heart failure due to the physiological changes during pregnancy and the stress of labor and delivery. Monitoring for signs of heart failure, such as shortness of breath, fatigue, and swelling in the extremities, is crucial for early detection and intervention. While monitoring weight, blood pressure, and fluid intake and output are important aspects of postpartum care, the priority for a client with cardiac disease is to monitor for signs of heart failure to prevent complications and provide timely treatment.
Question 2
A nurse is caring for a client who refuses a prescribed medical procedure. Which of the following actions should the nurse take to act as the client’s advocate?
A. Evaluate the client’s concerns and communicate them to the provider.
B. Ask the client’s partner to find out why the client has refused the procedure.
C. Explain the necessity of the procedure to the client.
D. Contact the unit’s social worker to report the client’s refusal.
Show answer and rationale
Correct answer: A — Evaluate the client’s concerns and communicate them to the provider.
Option A is the correct answer because as the client's advocate, the nurse should prioritize the client's autonomy and right to make informed decisions about their healthcare. By evaluating the client's concerns and effectively communicating them to the healthcare provider, the nurse ensures that the client's wishes and preferences are respected. This approach promotes shared decision-making and allows the client to actively participate in their care. Options B, C, and D do not prioritize the client's autonomy or involve them in the decision-making process, making them less appropriate actions for advocating on behalf of the client.
Question 3
A nurse is providing teaching to a client who has mild preeclampsia and will be caring for herself at home during the last 2 months of pregnancy. Which of these following statements by the client indicates an understanding of the teaching?
A. I will count baby\'s kicks every other day.
B. I will alternate the arm use to check my blood pressure.
C. I will consume 50 grams of protein daily.
D. I will consume 80 grams of protein daily.
Show answer and rationale
Correct answer: C — I will consume 50 grams of protein daily.
The correct answer is C because consuming 50 grams of protein daily is an appropriate recommendation for a client with mild preeclampsia. Adequate protein intake is important for supporting the growth and development of the fetus while managing preeclampsia. Option A is incorrect as counting baby's kicks every other day may not provide timely information about the baby's well-being. Option B is incorrect as alternating arm use for checking blood pressure does not directly relate to managing preeclampsia. Option D is incorrect as consuming 80 grams of protein daily may be excessive and unnecessary for a client with mild preeclampsia.
Question 4
.A nurse is caring for a client who has been diagnosed with obsessive-compulsive personality disorder. Which of the following behaviors should the nurse expect?
A. Perfectionism
B. Flexibility
C. Generosity
D. Spontaneity
Show answer and rationale
Correct answer: A — Perfectionism
The correct answer is A: Perfectionism. Obsessive-compulsive personality disorder is characterized by a preoccupation with orderliness, perfectionism, and control. Individuals with this disorder often have strict standards and may become preoccupied with details, rules, and schedules. They tend to be inflexible and have difficulty delegating tasks. The other options, flexibility, generosity, and spontaneity, are not typical behaviors associated with obsessive-compulsive personality disorder. Therefore, the nurse should expect the client to exhibit behaviors such as perfectionism and rigidity in their interactions and daily routines.
Question 5
A nurse is reinforcing teaching with a client about the use of a peak flow meter. Which of the following actions should the nurse make first?
A. Determine the client’s knowledge of the use of the peak flow meter.
B. Show the client a video demonstration of peak flow meter use.
C. Observe the client using the peak flow meter.
D. Emphasize the importance of the daily use of the peak flow meter.
Show answer and rationale
Correct answer: A — Determine the client’s knowledge of the use of the peak flow meter.
The correct answer is A: 'Determine the client's knowledge of the use of the peak flow meter.' Before providing any education or interventions, it is essential for the nurse to assess the client's existing knowledge base. This initial step will help the nurse understand the client's current understanding, identify any misconceptions, and tailor the teaching plan accordingly. By assessing the client's knowledge first, the nurse can ensure that the teaching is individualized and effective. Options B, C, and D involve actions that can be taken after assessing the client's knowledge and are not the initial step in the teaching process.
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Question 6
.A nurse is providing education to the family of a client who has been diagnosed with schizophrenia. Which of the following instructions should the nurse include?
A. Encourage the client to participate in daily activities.
B. Encourage the client to express their feelings.
C. Encourage the client to avoid caffeine.
D. Encourage the client to spend time alone.
Correct answer:
The correct answer is A: 'Encourage the client to participate in daily activities.' Engaging in daily activities can help the client maintain a routine and structure, which is beneficial for managing symptoms of schizophrenia. Being active can also improve mood and reduce stress. Options B and D may isolate the client and worsen symptoms, while option C, 'Encourage the client to avoid caffeine,' is not directly related to managing schizophrenia. Therefore, encouraging participation in daily activities is the most appropriate instruction for the client's family to support their loved one's well-being and management of the condition.
A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The newborn\'s mother asks about the swollen area on her son\'s head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse?
A. Mongolian spots can be found on the skin of many newborns.
B. A caput succedaneum occurs due to compression of blood vessels.
C. This is a cephalhematoma, which can occur spontaneously.
D. This is erythema toxicum, which is a transient condition.
Correct answer:
The correct answer is B: 'A caput succedaneum occurs due to compression of blood vessels.' A caput succedaneum is a common condition in newborns resulting from pressure on the baby's head during the birth process, usually due to the use of a vacuum extractor. It is characterized by swelling that crosses suture lines and is caused by fluid collecting between the scalp and skull. Mongolian spots (A) are blueish marks on the skin, cephalhematoma (C) is a collection of blood between the skull and periosteum, and erythema toxicum (D) is a harmless rash. Therefore, option B is the most appropriate response by the nurse in this situation.
When describing the process of fertilization to a group of clients, the nurse explains that fertilization of the ovum usually occurs in the:
A. Uterus
B. Fallopian tube
C. Ovary
D. Cervix
Correct answer:
The correct answer is B: Fallopian tube. Fertilization typically occurs in the fallopian tube. After ovulation, the mature egg is released from the ovary and travels through the fallopian tube. If sperm is present in the fallopian tube during this time, fertilization can occur. The uterus is where the fertilized egg implants and develops into a fetus. The ovary releases the egg but does not typically serve as the site of fertilization. The cervix is the lower part of the uterus that connects to the vagina and does not play a role in fertilization. Therefore, the fallopian tube is the most likely location for fertilization to occur.
A nurse is assessing the family structure of a child. Which of the following should the nurse include?
A. Parenting styles and roles
B. Family support systems
C. Family\'s health history
D. Family\'s educational level
Correct answer:
When assessing a child's family structure, the nurse should include parenting styles and roles as these are crucial aspects that influence the child's development and well-being. Understanding how parents interact with and care for the child provides insight into the family dynamics. Family support systems, while important, focus more on external resources and assistance available to the family. The family's health history and educational level, while relevant to the child's overall health and academic success, are not directly related to the family structure. Therefore, option A is the most appropriate choice for this assessment.
Which of the following is not related to a drug toxicity of Prednisone?
A. Cataracts
B. Hypotension
C. Psychosis
D. Acne
Correct answer:
The correct answer is B: 'Hypotension.' Prednisone is a corticosteroid medication commonly used to treat inflammatory conditions. While Prednisone can cause a range of side effects due to its impact on the body's immune and inflammatory responses, hypotension, or low blood pressure, is not typically associated with its toxicity. Common drug toxicities of Prednisone include cataracts, psychosis, and acne. Cataracts can develop in the eyes with long-term use of Prednisone, psychosis can occur as a rare side effect, and acne is a common dermatologic side effect. Therefore, hypotension is not directly related to Prednisone toxicity.
The nurse is assessing a child and notes small, round, red lesions that are raised and filled with pus. The lesions are clustered together and have a honey-colored crust. What is the most likely cause of these lesions?
A. Chickenpox
B. Impetigo
C. Scabies
D. Ringworm
Correct answer:
The correct answer is B: Impetigo. Impetigo is a highly contagious bacterial skin infection commonly seen in children. The description of small, round, red lesions filled with pus, clustered together, and having a honey-colored crust is characteristic of impetigo. Chickenpox typically presents as itchy, fluid-filled blisters that scab over. Scabies is caused by mites burrowing into the skin, resulting in intense itching and a rash with burrow tracks. Ringworm is a fungal infection that causes a red, circular rash with raised edges. Therefore, based on the description provided, impetigo is the most likely cause of these lesions.
The nurse in a clinic is teaching a client of childbearing age about recommended folic acid supplements. Which of the following defects can occur in the fetus or neonate as a result folic acid deficiency?
A. iron deficiency anemia
B. Poor bone formation
C. Macrosomia fetus
D. Neural tube defect
Correct answer:
The correct answer is D: Neural tube defect. Folic acid is crucial for preventing neural tube defects in developing fetuses. These defects can lead to serious conditions such as spina bifida and anencephaly, affecting the spinal cord and brain. Iron deficiency anemia (A) is not directly related to folic acid deficiency. Poor bone formation (B) is more commonly associated with calcium and vitamin D deficiencies. Macrosomia fetus (C) refers to a large baby, which is not typically caused by folic acid deficiency. Therefore, the most significant defect linked to folic acid deficiency in the fetus or neonate is a neural tube defect.
A nurse is teaching a client who is at 41 weeks of gestation about a non-stress test. Which of the following information should the nurse include in the teaching?
A. This test will confirm fetal lung maturity.
B. This test will determine adequacy of placental perfusion.
C. This test will detect fetal infection.
D. This test will predict maternal readiness for labor.
Correct answer:
The correct answer is B: 'This test will determine the adequacy of placental perfusion.' At 41 weeks of gestation, the non-stress test is commonly used to assess the well-being of the fetus by monitoring fetal heart rate patterns in response to its own movements. The test helps determine if the placenta is providing enough oxygen and nutrients to the fetus. It is not used to confirm fetal lung maturity (A), detect fetal infection (C), or predict maternal readiness for labor (D). By understanding the purpose of the non-stress test, the client can be informed about the importance of monitoring fetal well-being in late pregnancy.
A nurse is preparing to administer methylergonovine 0.2 mg orally to a client who is 2 hr. postpartum and has a boggy uterus. For which of the following assessment findings should the nurse withhold the medication?
A. Blood pressure 142/92 mm Hg
B. Urine output 100 mL in hr.
C. Pulse 58/min
D. Respiratory rate 14/min
Correct answer:
The correct answer is A. Methylergonovine is a medication used to treat postpartum hemorrhage by causing uterine contractions. A blood pressure of 142/92 mm Hg is elevated and indicates hypertension. Administering methylergonovine in this situation can potentially worsen hypertension and increase the risk of adverse effects such as stroke. It is important to withhold the medication and consult with the healthcare provider for further evaluation and management. The other assessment findings (urine output, pulse rate, and respiratory rate) are within normal limits and do not contraindicate the administration of methylergonovine.
A nurse is caring for a client following an amniocentesis. The nurse should observe the client for which of the following complications?
A. Hyperemesis
B. Proteinuria
C. Hypoxia
D. Hemorrhage
Correct answer:
The correct answer is D: 'Hemorrhage.' Following an amniocentesis, there is a risk of hemorrhage due to the needle puncture into the amniotic sac. The nurse should closely monitor the client for any signs of bleeding such as abdominal pain, vaginal bleeding, or signs of hypovolemic shock. Hyperemesis (A) is excessive vomiting, not typically associated with amniocentesis. Proteinuria (B) is the presence of excess protein in the urine, which is not a common complication of amniocentesis. Hypoxia (C) is a condition where the body is deprived of adequate oxygen supply, which is not directly related to amniocentesis complications.
RN exams clinical judgment practice questions, set 164 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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